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The authors of the study suggest that gender reassignment surgery may increase psychiatric problems for some people and decrease them for other people.

The study looked at the medical records of 104 people who had sex reassignment surgery in Denmark between 1978 and 2000.

They found that there was no statistically significant difference between the number of psychiatric diagnoses before surgery and after surgery.

In addition, the people who had diagnoses before surgery were different from the people who had diagnoses after surgery. Only 6.7% of the group had a psychiatric diagnosis both before and after surgery while 27.9% of the group had a psychiatric diagnosis before surgery and 22.1% had one afterwards.

According to the authors “this suggests that generally SRS may reduce psychological morbidity for some individuals while increasing it for others.”

The study also found that:

Psychiatric diagnoses were over-represented both before and after surgery (i.e. the group had more psychiatric issues than the general population).

Trans men (born female) had a significantly higher number of psychiatric diagnoses overall; there were no other statistically significant differences between trans men and trans women.

At the same time “significantly more psychiatric diagnoses were found before SRS for those assigned as female at birth.”

10 people had died at an average age of 53.5 years.

Questions for the Future

The most important question is, of course, how can we make sure that SRS does not increase psychiatric problems in the future?

Is it a question of better screening to identify gender dysphoria?

Do people need more support and counseling after surgery?

Should some people transition without getting surgery?

Were poor surgical outcomes linked to psychiatric problems?

Could low hormone levels after surgery cause problems for some people?

Were people’s problems caused by the surgery or some other aspect of transition that happened after surgery?

Or to put it another way, how do we identify which people might benefit from surgery and which might be hurt by it? or do we need to make other changes to prevent new psychiatric diagnoses after surgery?

It would also be helpful to know more about the specific psychiatric diagnoses before and after surgery. Are we seeing increases in depression, anxiety, eating disorders, or what?

How did the patients whose mental health improved compare to those whose mental health got worse? Were they older or younger? What were their life circumstances?

What does it mean that trans men had more psychiatric diagnoses before surgery? Was surgery more beneficial for them than for trans women or did trans men just have more psychiatric problems overall?

How long after surgery did people get the new psychiatric diagnoses?

More about the study:

Only the abstract of the study is available online, so it is hard to interpret some of their results.

The abstract gives few further details on their methodology, but a similar study of physical illnesses and death looked at the records of 56 trans women (born male) and 48 trans men (born female). The follow-up period began when people received permission for surgery. The group used in the other study represented 98% of all people who officially had SRS in Denmark from 1978 to 2000.

This is a 2007 review of research on gender reassignment surgery. It shows clearly that we need more research in this area.

The research is not strong enough to evaluate the efficacy of gender reassignment surgery in general. In addition, we do not have a way to evaluate particular surgeries.

From the abstract:

“The evidence concerning gender reassignment surgery in both MTF and FTM transsexism has several limitations in terms of: (a) lack of controlled studies, (b) evidence has not collected data prospectively, (c) high loss to follow up and (d) lack of validated assessment measures. Some satisfactory outcomes were reported, but the magnitude of benefit and harm for individual surgical procedures cannot be estimated accurately using the current available evidence.”

The authors reviewed all the articles they could find on gender reassignment surgeries from 1980 onwards. The review took place in October and November 2005.

The great strength of this review is that they looked at individual surgical procedures. Too often studies lump together all gender reassignment surgeries and then evaluate whether or not they were effective. It is possible that some surgeries are more helpful for people’s mental well-being than others. In addition, some surgeries may have better physical outcomes or fewer risks than others. The physical outcomes could certainly affect people’s mental well being as well.

They did not find enough good studies looking at individual surgeries; there is a great need for more such studies. We need to know what are the complications and problems with various surgeries. Are some techniques better than others? Do some medical centers have better physical outcomes than others?

Only a few of the studies reported on patients’ well-being, mental health, or satisfaction; these studies had the same methodological weaknesses as the others.

This is the main finding of the review – we don’t have great data and we need further research. You can read more about some of the specific surgical procedures here.

The authors discuss the quality of research and directions for future research; I have included their discussion below.

Discussion

In the first section concerning MTF surgical procedures, 38 published papers met the inclusion criteria (23 case series and 15 case studies) with an additional 13 papers excluded (four case series, three case studies, four reviews, one prospective non-randomized controlled study, one expert opinion). The level of included evidence was of poor quality. There was a clear lack of randomized controlled evidence and only one excluded study included a control group comparison. No studies met the inclusion criteria for labiaplasty, orchidectomy or penectomy procedures. A large amount of evidence is available reporting vaginoplasty and clitoroplasty procedures. Some complications have been reported. All the studies report, to various degrees, satisfactory outcomes in terms of being able to have penetrative sexual intercourse and achieving sexual fulfilment.

In the second section concerning FTM surgical procedures, 44 published papers met the inclusion criteria (26 case series, 17 case studies, one cohort study) with an additional 19 papers being excluded (seven reviews, five expert opinions, four case series, three case studies). The majority of included evidence was of poor quality. Many of the studies reported good satisfactory outcomes with few complications for each of the individual procedures. The main outcomes reported were the ability to perform penetrative sexual intercourse and achieve orgasm. Another key factor requested by many FTM patients was the ability to void whilst standing. Whilst successful results were reported by many studies for phalloplasty procedures, an inability to perform sexual penetration due to the construction of a small phallus was a common problem reported following the metoidioplasty procedure. Some of the FTM core surgical procedures are frequently completed along with other surgery, making it difficult to assess the effectiveness of each procedure alone. Furthermore, the assessment of effectiveness is also confounded by the lack of controlled evidence, unclear outcome measures, and a reliance on case series and case studies.

Six previous reviews have reported the clinical effectiveness of GRS. Six reviewed evidence in MTF patients and three of these also reviewed evidence in FTM patients. Of these, three were systematic reviews. These earlier reviews provide a summary of approximately 172 individual studies. Two recent unpublished reports provided a brief summary of some of the reviews. Several key points were raised in these previous reviews. The first related to the quality of the evidence and study design. Concerns were raised about the lack of randomized controlled evidence, the majority of evidence involved case studies and case series, with few studies using group comparisons, standardized measures or the follow up of participants. A second concern related to the validity of findings. Many studies involved a combination of different surgical procedures. Thirdly, there was concern about the validity of outcome measures. Despite many reports of positive outcomes of patients, there was little consensus of how to measure effectiveness. The large range of outcomes reported across studies makes it difficult to accurately evaluate the overall outcomes of individual surgical procedures.

Several previous reviews reported a controlled study which compared 20 patients having immediate surgery with 20 patients awaiting surgery for penectomy, orchidectomy and the construction of a neovagina. The remaining studies reflect lower grades of evidence, and had further problems in their design such as selected patient groups, retrospective analysis and losses to follow up. Conclusions from the reviews are understandably tentative, but highlight improvements in patients across most studies, although 10–15% of patients with transsexism who undergo GRS have poor outcomes.

The quality of evidence included in this review has been poor due to the lack of concealment of allocation, completeness of follow up and blinding. As well as the fundamental limitation in study design, several other issues regarding the interpretation of the evidence are worth consideration. Firstly, all the reviews, and many of the individual studies within them, examine different types of GRS. The Mate-Kole study, for example, is essentially an evaluation of three surgical techniques. Clearly, trying to reach a robust conclusion about GRS as a whole is not possible when the combination of techniques varies across studies. Secondly, the patient populations within, and across studies, are heterogeneous and we have little idea about the referral, diagnosis, assessment and selection processes that precede inclusion within the studies. Consequently, Brown concludes that a lengthy differential diagnosis and a specialized approach to interviewing gender dysphoric patients are needed. Thirdly, the choice of outcome measures varies across studies, with very little use of validated health-related quality of life (QOL) measures. This complicates further our ability to draw conclusions, and also limits the commissioners’ ability to identify studies that use outcomes that are relevant to their role. Finally this review has focused on a subset of surgical procedures that are used within this field. Whilst these are considered to be the most routine, it is recognized that other procedures are currently used and these too need to be critically appraised in future reviews.

No published evidence on cost-effectiveness was found. Best and Stein speculate that some cost offsets are possible following surgery due to the reduced need for psychiatric and hormonal treatment, but no evidence is available for this. The lack of generic QOL measures means that measures of cost-effectiveness that can be used to assess value for money relative to other healthcare interventions are not possible.

When trying to consider all of the evidence together, there is a dilemma regarding its interpretation. Reviews of heterogeneous patient groups and interventions clearly give the greatest depth of evidence, but give little in the way of specific information that is of use to purchasers. In contrast, studies of individual techniques have a more limited evidence base but allow us to focus on specific clinical questions with more consistent reporting. But these provide information on purchasing decisions that are less realistic, as some procedures are unlikely to be purchased in isolation. In between these extremes, are sets of studies that investigate various combinations of multiple procedures, but matching these studies to the activity of different providers and patients, is extremely complex.

Taking this reasoning further, some would argue that assessment of GRS in isolation is difficult to interpret, as it is the final step in a longer treatment process. This is more contentious, as many patients do not reach the point of referral for surgery and many do not wish to undergo any surgery. Also, taking this argument to its extreme would require studies of the effectiveness of treatment from initial diagnosis to the end of post-surgical follow up; such studies do not exist.

Despite these difficulties in interpretation of review evidence the conclusion about the strength of evidence regarding GRS appears clear: little robust evidence exists.

Future research

There is a need for good quality controlled trials based on clearly defined diagnosis and assessment criteria.

An important consideration for future studies is how best to evaluate the effectiveness of a surgical procedure. One possibility is assessment of patient satisfaction and regret following surgery. More importantly is the need for standardised measures to assess the outcome of surgery. One suitable method, which has received limited research, is the use of QOL measures in samples before and after GRS. Rakic et al.investigated several aspects of QOL after GRS in 32 patients with transsexism (22 MTF, 10 FTM). Four aspects of QOL were examined: sexual activity; attitude towards the patients’ own body; relationships with other people; and occupational functioning. For the majority of persons with transsexism, QOL improved after surgery in terms of these aspects. All patients (100%) were satisfied with their GRS. However, only 20 patients (62%) were satisfied with how their bodies looked. In a study by Barrett, they used the General Health Questionnaire and assessments of depression inpatient groups. More controlled studies using this type of experimental design are needed to provide a better measure of surgical effectiveness.

For many patients undergoing GRS, their desire is to look ‘normal’ and be capable of having a normal sexual relationship. The results presented in this review have provided little evidence on how successful individual surgical procedures are in achieving these goals. Further research is needed to investigate these specific outcome measures of satisfaction and function.

In conclusion, we have confirmed the findings from previous reviews that the evidence to support GRS has several limitations in terms of: (a) lack of controlled studies; (b) evidence has not collected data prospectively; (c) high loss to follow up; and (d) lack of validated assessment measures. We have extended these findings from previous reviews by providing a summary of the evidence available for each of the ‘core’ procedures for MTF and FTM transsexism. In the majority of studies a large number of persons with transsexism experience a successful outcome in terms of subjective well being, cosmesis, and sexual function. We conclude that the magnitude of benefit and harm cannot be estimated accurately using the current available evidence.

This is a 2007 review of research on gender reassignment surgery. The authors found that there was not enough strong research to evaluate gender reassignment surgery; you can read more about the study as a whole here. This article looks more at specific surgical procedures.

The authors of the review evaluated individual surgical procedures rather than just looking at the outcome of all gender reassignment surgeries together. This allows a better understanding of which procedures are the most effective. It also means excluding some studies that looked at more than one procedure.

The authors reviewed all the articles they could find on specific gender reassignment surgeries from 1980 onwards. The review took place in October and November 2005.

The following are some of the results they found for specific surgeries. There is not enough data to definitively evaluate particular procedures and techniques, but there is useful information on possible complications. Clearly, however, we need more research.

Surgeries for Trans Women (born male)

Clitoroplasty/neoclitoris construction – The authors reviewed three studies that used a range of surgical techniques. The results were generally good but in one study 2 out of 10 patients had necrosis of the neoclitoris; in another study three out of nine patients did not report sexual satisfaction.

“All three included papers reported successful results in terms of function and cosmetic appearance with few or no complications (e.g. urine leakage). Rehman and Melman reported that the neoclitoris had remained intact postoperatively in eight out of 10 patients and the functional and cosmetic appearance was comparable to a normal clitoris. In two patients, however, the results were not satisfactory because of necrosis of the neoclitoris.

Using the dorsal portion of the glans penis with the dorsal neurovascular pedicle for clitoroplasty, the neoclitorides in nine patients survived well, and six patients reported sexual satisfaction. However, the transpositioning of glans on the long dorsal neurovascular pedicle appears to be a procedure with high risks.Overall, several studies have reported that the neoclitoris construction can result in good preservation of light touch and sexual sensation.“

Vaginoplasty/neovagina construction – The authors reviewed 32 studies. Satisfactory cosmetic and functional results were reported in many of the studies, although one found that “vaginoplasty combining inversion of the penile and scrotal skin flaps produced poor functional outcomes.”

In addition, according to the abstract of the 2001 study, “Minor complications, e.g. meatal stenosis in seven patients, occurred in 24 (36%) of patients. Ten patients with insufficient penile skin had the phallic cylinder augmented with a free-skin mesh graft, but in three of these patients an ileal augmentation was finally constructed because scarring occurred at the suture line between the penile skin and the augmented graft.”

At the same time, 47% of the patients in the 2001 study completed a follow-up questionnaire and almost all of them reported that they were “satisfied with the cosmetic result and capacity for orgasm.” Over half of the people who answered the follow-up questionnaire had had sexual intercourse.It is not clear if the satisfied group included the people who had had complications.

It would be good to have more information to compare to the German results. Are these rates of complications normal?

The reviewers did not find studies that met their criteria for labiaplasty, orchidectomy, or penectomy.

Surgeries for Trans Men (born female)

Hysterectomy – The authors only reviewed one study that met their criteria; it reported successful operations for two trans men. The study also reported that “a laparoscopic hysterectomy using the McCartney tube for FTM GRS was a useful procedure in overcoming difficulties encountered due to restricted vaginal access.”

Mastectomy – The authors reviewed three studies: “Colic and Colic found the use of a circumareolar approach for subcutaneous mastectomy produced flatter masculine breasts, leaving sufficient dermal vascularization for the nipple-areola complex. Of the 12 FTM patients all were very satisfied with the outcomes of surgery mainly because of the periareolar scar. It was reported, however, that two areolar necroses occurred due to perforation of the thin vascular dermal pedicle.”

Metoidioplasty – The authors reviewed two studies.

In the first, the procedure was successful for 32 patients with an average hospital stay of 11 days. One patient had a severe haematoma (solid swelling of clotted blood), but there were no other complications.

In the second study, 17 patients were satisfied with the size and appearance of their penis, but 5 people required additional augmentation phalloplasty. In two cases, the trans men developed urethral stenosis (narrowing of the urethra) and in three cases they developed fistula. The complications were related to the urethroplasty.

The reviewers add: “The metoidioplasty procedure produces a very small phallus (e.g. mean = 5.7 cm, range = 4–10 cm),hardly capable of sexual penetration, if at all. Only 10 of the 32 patients were able to void whilst standing. It should be noted that in the study by Hage et al, 18 patients combined the metoidioplasty procedure with the construction of a bifid scrotum in which testicular prostheses were implanted. Overall these two studies found metoidioplasty was an appropriate method where the clitoris seems large enough to provide a phallus and satisfies the patient.”

Phalloplasty – There is only limited data on the outcomes of phalloplasty, although two studies reported good outcomes in terms of size and stiffness and one reported good psychological outcomes.

However, there are a range of procedures and they have mixed results.

Serious complications have been reported and phalloplasty leaves a scar somewhere on the body.

One study found that creating the neourethra in two stages could reduce complications.

Another study using a suprapubic abdominal wall flap produced a good cosmetic appearance for 68% of the people; presumably 32% of the trans men had phalluses that did not look as good. A small study of using a lateral arm free flap reported good results.

“There appear to be limited data on outcome measures, including social integration, patient satisfaction and physiological function. Good operative results have been reported in terms of appropriate size and stiffness without vascular compromise and in terms of psychological outcomes. In addition to an aesthetically appealing look either while being nude (81%) or wearing a tight swim suit (91%), to void whilst standing appears to be an important goal for many FTM patients. It is important to recognize that there are a range of phalloplasty procedures available with mixed findings being reported in terms of effectiveness. Hage et al. reported several serious complications such as vesicovaginal, urethrovaginal fistulas and urinary incontinence. Furthermore, unlike the metoidioplasty procedure, free flap phalloplasty techniques produce extensive scarring to the donor site, unless techniques such as tissue expansion are used. Of the 85 FTM patients who had a phalloplasty fashioned from suprapubic abdominal wall flap that was tubed to form the phallus, Bettocchi et al. reported the cosmetic appearance of the phallus was considered good in 68% of the patients. Major complications (n = 60) were associated with the neourethra (75%), stricture formation (64%) and/or fistulae (55%). It should be noted that the complication rates found by Bettocchi et al. were significantly less (P < 0.001) when the neourethra was created in two stages. In contrast, Khouri et al. concluded by using a prefabricated lateral arm free flap technique it is possible to achieve a fully functional penis with stable long-term results and excellent patient satisfaction.”

Scrotoplasty/scrotum construction/testicular prosthesis – The authors reviewed two studies that met their criteria. “This procedure is generally accomplished by hollowing out the labia majora, inserting silicone implants, and attaching the labia to develop a single scrotal sac. Implant expulsion, rupture or dislocation is encountered in a small number of patients.”

Urethroplasty – The authors did not find any studies that met their criteria, but they reported that “A one-stage total phalloplasty and urethroplasty was associated with a significant rate of fistulas and strictures.”

The authors did not find studies that met their criteria for Salpingo-oophorectomy or vaginectomy/vaginal closure.

The authors conclude that “There is a need for good quality controlled trials based on clearly defined diagnosis and assessment criteria.”

And, “we have confirmed the findings from previous reviews that the evidence to support GRS has several limitations in terms of: (a) lack of controlled studies; (b) evidence has not collected data prospectively; (c) high loss to follow up; and (d) lack of validated assessment measures. We have extended these findings from previous reviews by providing a summary of the evidence available for each of the ‘core’ procedures for MTF and FTM transsexism. In the majority of studies a large number of persons with transsexism experience a successful outcome in terms of subjective well being, cosmesis, and sexual function. We conclude that the magnitude of benefit and harm cannot be estimated accurately using the current available evidence.”